A novel method to promote physical activity among older adults in residential care: an exploratory field study on implicit social norms.

BACKGROUND: Physical activity (PA) levels of older adults living in a care setting are known to be very low. This is a significant health(care) problem, as regular PA has many health benefits also at advanced age. Research on automatic processes underlying PA behaviour in physically inactive older adults is yet non-existing. Since people are unconsciously influenced by people around them (i.e. by 'social norms') automatic processes could be used to promote PA. We developed an explorative intervention method to assess the effects of automatically processed (implicit) descriptive social norms ('What most people do') on behavioral intention and participation in PA offered in a local residential care setting. METHODS: Forty-seven care clients met the inclusion criteria. Participants (response 45%; unaware of the intention of the research) were randomly assigned to an experimental (N = 10) or a control group (N = 11). The experimental group was exposed to photos and text heading on active peers (physically active implicit descriptive norm) using a draft newsletter article they were asked to comment on, whereas the control group was exposed to a newsletter with photos and text heading of inactive peers (physically inactive implicit descriptive norm). Subsequently, we tested (Fishers exact p < 0.10) whether this unaware exposure predicted intention (implicit and explicit) to participate in PA offered and organized by the care center (e.g. walking, gymnastics) and self-reported participation in organised PA at three months follow-up. Participants were debriefed later. RESULTS: Mean age was 87 years (SD = 3.6; range 80-95) and 53% of the participants were male. At baseline, there were no significant differences in self-rated health and PA between the experimental and control group. Results indicated that implicit descriptive norm information was associated with implicit PA intention (p = .056, Fisher's exact test). No significant effects were found on explicit intention. At 3 months follow-up the experimental group self-reported 80% participation in PA versus 22% in the control group (Fisher's exact test p = 0.027). CONCLUSION: Implicit descriptive social norm information could indeed be a potentially effective way to encourage inactive older adults in residential care to engage in organized PA.

Using a retrospective pretest instead of a conventional pretest is replacing biases: a qualitative study of cognitive processes underlying responses to thentest items.

BACKGROUND: The thentest design aims to detect and control for recalibration response shift. This design assumes (1) more consistency in the content of the cognitive processes underlying patients' quality of life (QoL) between posttest and thentest assessments than between posttest and pretest assessments; and (2) consistency in the time frame and description of functioning referenced at pretest and thentest. Our objective is to utilize cognitive interviewing to qualitatively examine both assumptions. METHODS: We conducted think-aloud interviews with 24 patients with cancer prior to and after radiotherapy to elicit cognitive processes underlying their assessment of seven EORTC QLQ-C30 items at pretest, posttest and thentest. We used an analytic scheme based on the cognitive process models of Tourangeau et al. and Rapkin and Schwartz that yielded five cognitive processes. We subsequently used this input for quantitative analysis of count data. RESULTS: Contrary to expectation, the number of dissimilar cognitive processes between posttest and thentest was generally larger than between pretest and posttest across patients. Further, patients considered a range of time frames when answering the thentest questions. Moreover, patients' description at the thentest of their pretest functioning was often not similar to that which was noted at pretest. Items referring to trouble taking a short walk, overall health and QoL were most often violating the assumptions. CONCLUSIONS: Both assumptions underlying the thentest design appear not to be supported by the patients' cognitive processes. Replacing the conventional pretest-posttest design with the thentest design may simply be replacing one set of biases with another.

Do major life events influence physical activity among older adults: the Longitudinal Aging Study Amsterdam.

BACKGROUND: Major life events are associated with a change in daily routine and could thus also affect habitual levels of physical activity. Major life events remain largely unexplored as determinants of older adults' participation in physical activity and sports. This study focused on two major life events, widowhood and retirement, and asked whether these major life events were associated with moderate to vigorous physical activity (MVPA) and sports participation. METHODS: Data from the first (1992-93) and second (1995-96) wave of the Longitudinal Aging Study Amsterdam (LASA), a prospective cohort study among Dutch adults aged 55 and older, were used. Change in marital status and employment status between baseline and follow-up was assessed by self-report. Time spent in MVPA (min/d) and sports participation (yes/no) was calculated based on the LASA Physical Activity Questionnaire. The association of retirement and widowhood with MVPA and sports participation was assessed in separate multivariate linear and logistic regression analyses, respectively. RESULTS: Widowhood - N=136 versus 1324 stable married- was not associated with MVPA (B= 3.5 [95%CI:-57.9;64.9]) or sports participation (OR= 0.8 [95%CI:0.5;1.3]). Retired participants (N= 65) significantly increased their time spent in MVPA (B= 32.5 [95%CI:17.8;47.1]) compared to participants who continued to be employed (N= 121), but not their sports participation. Age was a significant effect modifier (B= 7.5 [90%CI:-1.1;13.8]), indicating a greater increase in MVPA in older retirees. DISCUSSION: Our results suggest that the associations found varied by the two major life events under investigation. MVPA increased after retirement, but no association with widowhood was seen.

Determinants of physical activity and exercise in healthy older adults: a systematic review.

BACKGROUND: The health benefits of regular physical activity and exercise have been widely acknowledged. Unfortunately, a decline in physical activity is observed in older adults. Knowledge of the determinants of physical activity (unstructured activity incorporated in daily life) and exercise (structured, planned and repetitive activities) is needed to effectively promote an active lifestyle. Our aim was to systematically review determinants of physical activity and exercise participation among healthy older adults, considering the methodological quality of the included studies. METHODS: Literature searches were conducted in PubMed/Medline and PsycINFO/OVID for peer reviewed manuscripts published in English from 1990 onwards. We included manuscripts that met the following criteria: 1) population: community dwelling healthy older adults, aged 55 and over; 2) reporting determinants of physical activity or exercise. The outcome measure was qualified as physical activity, exercise, or combination of the two, measured objectively or using self-report. The methodological quality of the selected studies was examined and a best evidence synthesis was applied to assess the association of the determinants with physical activity or exercise. RESULTS: Thirty-four manuscripts reporting on 30 studies met the inclusion criteria, of which two were of high methodological quality. Physical activity was reported in four manuscripts, exercise was reported in sixteen and a combination of the two was reported in fourteen manuscripts. Three manuscripts used objective measures, twenty-two manuscripts used self-report measures and nine manuscripts combined a self-report measure with an objective measure. Due to lack of high quality studies and often only one manuscript reporting on a particular determinant, we concluded "insufficient evidence" for most associations between determinants and physical activity or exercise. CONCLUSIONS: Because physical activity was reported in four manuscripts only, the determinants of physical activity particularly need further study. Recommendations for future research include the use of objective measures of physical activity or exercise as well as valid and reliable measures of determinants.

A 'short walk' is longer before radiotherapy than afterwards: a qualitative study questioning the baseline and follow-up design.

BACKGROUND: Numerous studies have indirectly demonstrated changes in the content of respondents' QoL appraisal process over time by revealing response-shift effects. This is the first known study to qualitatively examine the assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time. Specific objectives are to examine whether the content of each distinct cognitive process underlying QoL appraisal is (dis)similar over time and whether patterns of (dis)similarity can be discerned across and within patients and/or items. METHODS: We conducted cognitive think-aloud interviews with 50 cancer patients prior to and following radiotherapy to elicit cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Qualitative analysis of patients' responses at baseline and follow-up was independently carried out by 2 researchers by means of an analysis scheme based on the cognitive process models of Tourangeau et al. and Rapkin & Schwartz. RESULTS: The interviews yielded 342 comparisons of baseline and follow-up responses, which were analyzed according to the five cognitive processes underlying QoL appraisal. The content of comprehension/frame of reference changed in 188 comparisons; retrieval/sampling strategy in 246; standards of comparison in 152; judgment/combinatory algorithm in 113; and reporting and response selection in 141 comparisons. Overall, in 322 comparisons of responses (94%) the content of at least one cognitive component changed over time. We could not discern patterns of (dis)similarity since the content of each of the cognitive processes differed across and within patients and/or items. Additionally, differences found in the content of a cognitive process for one item was not found to influence dissimilarity in the content of that same cognitive process for the subsequent item. CONCLUSIONS: The assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time was not found to be in line with the cognitive processes described by the respondents. Additionally, we could not discern patterns of (dis)similarity across and within patients and/or items. In building on cognitive process models and the response shift literature, this study contributes to a better understanding of patient-reported QoL appraisal over time.

Somatically ill persons' self-nominated quality of life domains: review of the literature and guidelines for future studies.

OBJECTIVE: To review which domains somatically ill persons nominate as constituting their QoL. Specific objective is to examine whether the method of enquiry affect these domains. METHODS: We conducted two literature searches in the databases PubMed/Medline, CINAHL and Psychinfo for qualitative studies examining patients' self-defined QoL domains using (1) SEIQoL and (2) study-specific questions. For each database, two researchers independently assessed the eligibility of the retrieved abstracts and three researchers subsequently classified all QoL domains. RESULTS: Thirty-six eligible papers were identified: 27 studies using the SEIQoL, and nine presenting data derived from study-specific questions. The influence of the method of enquiry on patients' self-nominated QoL domains appears limited: most domains were presented in both types of studies, albeit with different frequencies. CONCLUSIONS: This review provides a comprehensive overview of somatically ill persons' self-nominated QoL domains. However, limitations inherent to reviewing qualitative studies (e.g., the varying level of abstraction of patients' self-defined QoL domains), limitations of the included studies and limitations inherent to the review process, hinder cross-study comparisons. Therefore, we provide guidelines to address shortcomings of qualitative reports amenable to improvement and to stimulate further improvement of conducting and reporting qualitative research aimed at exploring respondents' self-nominated QoL domains.

Opening the black box of cancer patients' quality-of-life change assessments: a think-aloud study examining the cognitive processes underlying responses to transition items.

Transition items are a popular approach to determine the clinical significance of patient-reported change. These items assume that patients (1) arrive at a change evaluation by comparing posttest and pretest functioning, and (2) accurately recall their pretest functioning. We conducted cognitive think-aloud interviews with 25 cancer patients prior to and following radiotherapy. Two researchers independently analysed their responses using an analysis scheme based on cognitive process models of Tourangeau et al. and Rapkin and Schwartz. In 112 of the 164 responses to transition items, patients compared current and prior functioning. However, in 104 of these responses, patients did not refer to their functioning at pretest and/or posttest according to transition design's first assumption, but rather used a variety of time frames. Additionally, in 79 responses, the time frame employed and/or description of prior functioning provided differed from those employed in the corresponding pretest items. Transition design's second assumption was therefore not in line with the patients' cognitive processes. Our findings demonstrate that in interpreting transition assessments, one needs to be aware that patients provide change assessments, which are not necessarily based on the cognitive processes intended by researchers and health care providers.

Clarifying quality of life assessment: do theoretical models capture the underlying cognitive processes?

OBJECTIVE: To develop an analysis scheme capturing the cognitive processes underlying QoL assessment to increase our understanding on how to interpret responses to QoL items. Tourangeau et al.'s (The psychology of survey response, 2000) and Rapkin and Schwartz' (Health Qual Life Outcomes 2:14, 2004) cognitive process models form the basis for this analysis scheme. METHODS: We conducted think aloud interviews with six cancer patients prior to and following radiotherapy to elicit the cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Content analysis was carried out by two to four researchers independently. Eighty text fragments were analyzed inductively and combined in an iterative process with deductive analyses based on both models. RESULTS: We have developed a comprehensive analysis scheme feasible for analyzing the cognitive processes underlying QoL assessment qualitatively. All cognitive components of both models could be distinguished in our data. The cognitive component 'reporting and response selection' needed extension to fully capture the cognitive processes used. CONCLUSION: The two models combined are useful in describing the cognitive processes cancer patients use in answering QoL items, and as such facilitate insight into patients' self-reported QoL assessments. Interestingly, the content of the cognitive processes not only differed between patients but also between items within patients and over time.